Insurance and Payment

Common Terms

Premium: The amount of money you pay simply to have health insurance.

Co-payment (or co-pay): The predetermined amount a patient has to pay for a specific service, usually an office visit, emergency room visit, or for a specific tier of medication. This amount is paid for the visit or medication regardless of the billed charge. Co-pays rarely accumulate or apply to deductible or-out of-pocket maximum.

Deductible: The amount you have to pay each year before you insurance before your insurance pays anything. This is usually an annual deductible, so once it is met you don’t have to pay it again until it resets, often on January 1.

Coinsurance: Once you have paid your deductible, the insurance company splits the payment with you. As the patient, you will usually be paying for 10-30 percent of the cost (depending on the plan) while the insurance company pays the rest. Not all plans have coinsurance.

Out-of-pocket maximum: Once you have paid the out-of-pocket maximum, the insurance company pays the remaining amount in full. For instance, if you have a $5,000 out-of-pocket maximum, all charges above that amount are covered by the insurance company. These reset each year, usually on January 1.

Example: You have Medicare Part B and get an outpatient partial hip replacement at a cost of $5000. You would pay the $147 annual deductible and then 20 percent coinsurance for the remaining amount.

Paying for health care can sometimes be more confusing than health care treatment. While every situation is unique, this section should help consumers better understand how to pay for home care and related costs. Most major forms of insurance cover home health care (see below). Each plan may have different rules for covering home visits. These can include requiring a doctor’s order (most plans), a limitation on the number of visits in a year or requiring that the patient have extremely limited mobility.

Insurance Types

Medicare

There are several types of Medicare coverage, including Part A, Part B, Part D and Medicare Advantage.

Part A covers hospitalization and long-term care. Part A has no premiums for most people and covers 100 percent of associated cost for hospital care and approximately 66 percent for long-term care.

Part B covers doctor visits, home care, medical equipment, and outpatient surgery and cost most people about $104 each month in premiums. As shown in the example above, the patient pays a $147 deductible each year and then 20 percent of the charges that follow.

Part D is prescription drug coverage. There are many plans available and each plan as a monthly premium. To find a plan in your area, visit the Medicare Part D website.

Medicare Advantage plans are set up more like traditional insurance plans and follow a completely set of rules from traditional Part A and B. Only about 10,000 people in Iowa have an Advantage plan.

Private Insurance

Most private insurance policies cover home care, such as those from Wellmark Blue Cross and Blue Shield or Coventry Health Care. However, not all home health providers may be in a particular insurer’s network, meaning that a person might have to pay a lot more to get services from an out-of-network provider than one who contracts with their insurance carrier.

To see if your policy has a home health benefit, if a provider is in network, and what limitations might be on your policy, call the customer service number on your insurance card or visit their website before starting home care services.

State Programs

There are several programs people can join that cover some of the cost of home care.

Medicaid: If you have an income below 100 percent of federal poverty ($11,670 for one person, $23,850 for a family of four) and live in Iowa, you can receive health insurance through Medicaid at no cost. Medicaid covers home health visits.

Hawk-i: This is a program for children that offers low or no cost insurance plans for those who do not qualify for Medicaid.

Other Options

Worker’s Compensation and Automotive Insurance

These are two forms of accident insurance provide home health coverage. Let your home health provider know about your worker’s compensation coverage before starting treatment so your health insurance is not billed.

If you are receiving home health treatment as the result of an automobile accident, the person at fault’s insurance company should cover the cost of your treatment. If you caused the accident or there is a no-fault situation, your car insurance company may provide you limited coverage, but usually the responsibility will fall to your health insurance.

Active court cases for worker’s compensation or car accidents can delay payment for months or even years. Let your home health provider know the status of your case to avoid confusion or your account giving to collections.

Self-Pay

Even if you have insurance, it is likely that you will have some financial responsibility for your care. If you have no insurance, you will pay the full amount. While health care is rarely inexpensive, home care is far less expensive than paying for a skilled nursing facility or hospital care.

Also, private duty services are usually not covered by insurance. For all charges that remain, work with your local home care agency to set up a payment schedule that works with your budget.